Revised CMS Policy on Medicare Part D Drugs for Hospice Enrollees

CMS has revised its earlier policy on Medicare Part D payments for drugs used by beneficiaries enrolled in Medicare hospice. In a July 18, 2014 memo, CMS is modifying its March 10, 2014 guidance to Part D sponsors that imposed a prior authorization (PA) requirement for all drugs for hospice beneficiaries in light of operational issues and access concerns.  The revised guidance narrows the Part D hospice PA provision to four categories of drugs that the OIG, in consultation with hospice providers, has identified as nearly always covered under the hospice benefit. Specifically, CMS will now “strongly encourage” Part D sponsors to place beneficiary-level PA requirements only on: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics). Part D sponsors are not expected to place hospice PA requirements on other categories of drugs or take special measures beyond normal compliance and utilization review activities to retrospectively review paid claims to determine whether drugs in the other categories were unrelated to the hospice beneficiary’s terminal illness and related conditions or payment recovery.

Sunshine Act Open Payments System Review/Dispute Process Underway

CMS has made a series of announcements related to the Sunshine Act Open Payments system, including information about the Open Payments review, dispute and correction process that runs from July 14 through August 27, 2014. This period allows physicians and teaching hospitals to review and initiate any disputes they may have regarding the data reported about them by applicable manufacturers and applicable group purchasing organizations. CMS has also extensively updated the Open Payments User Guide, which is intended to provide industry, physicians, and teaching hospitals with a comprehensive understanding of the Open Payments system and reporting requirements.

CMS Announces Plans for Medicare DMEPOS Competitive Bidding Round 2 Recompete and National Mail-Order Recompete

On July 15, 2014, the Centers for Medicare & Medicaid Services (CMS) announced its plans to recompete the supplier contracts awarded in Round 2 of the Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program and the National Mail-Order diabetic testing supplies competition, as it is required by statute to do at least every three years.  The current contract period expires June 30, 2016; the new contracts will begin on July 1, 2016.  For the recompete, CMS is making changes to both the composition of the product categories (including adding new products) and the number of competitive bidding areas (CBAs).

The product categories to be included in the Round 2 Recompete are as follows:

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CMS Proposes Discontinuing 2 HCPCS Codes under New Demonstration

As recently announced, CMS is conducting what it describes as a “limited demonstration” of an internet-based notice and comment mechanism on internally-generated requests to discontinue Level II HCPCS codes.   CMS has just released details regarding the first two HCPCS codes it is proposing to remove under this process:

  • A7042 Implanted Pleural Catheter, Each.  CMS rationale:  the catheter is included in the procedure and therefore a separate code is unnecessary.
  • A9586 Florbetapir f18, diagnostic, per study dose, up to 10 millicuries.  CMS rationale:  HCPCS code A9599 “Radiopharmaceutical, Diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose” adequately describes this product.

CMS will accept public comments on the proposed HCPCS discontinuations until July 21, 2014.  Comments should be submitted to hcpcs@cms.hhs.gov, and include the following text in the subject line:  “COMMENT RE: DISCONTINUATION OF CODE _____.” 

HHS Provides Update on ACA Insurance Costs and Choices, Announces Management Changes

HHS has released a report on premiums, tax credits, and health plan choices on the ACA federal Marketplace for plans operating in 2014.  In addition, CMS has launched an initiative, dubbed “From Coverage to Care," designed to answer questions consumers may have about their new health coverage under the ACA and to help individuals make the most of their new benefits. The Administration also has announced a number of management changes at CMS designed to strengthen implementation of the ACA going forward, including a Principal Deputy Administrator to oversee ACA Marketplace and other agency operations, a Marketplace Chief Executive Officer, and a Marketplace Chief Technology Officer.

CMS Adds MAC/RAC "Provider Relations Coordinator" for Auditor Process Issues

In an effort to “increase program transparency and offer more efficient resolutions to providers” subject to the medical review process, CMS has created the new position of “Provider Relations Coordinator."  The Provider Relations Coordinator is intended to improve communication between providers and CMS on medical review process issues. For instance, providers can contact the Provider Relations Coordinator when an auditor is failing to comply with documentation request limits or has a pattern of not issuing review results letters in a timely manner. Providers also can submit recommendations for improving the Recovery Auditor or Medicare Administrative Contractor medical review process to the Provider Relations Coordinator.

CMS Plans Medicare Quality "Star" Ratings for Hospitals, Dialysis Facilities, Home Health

On June 18, 2014, CMS announced in a blog posting that it is planning to add a “Five Star” quality rating system to the Hospital Compare, Dialysis Facility Compare, and Home Health Compare websites on Medicare.gov. The agency will start making the new quality ratings available later this year and into early 2015. CMS already maintains star ratings on its Nursing Home Compare and Physician Compare sites.

CMS Releases Updated Hospital Charge Data, New Chronic Conditions & Geographic Variations Files

Earlier this month, CMS released its first annual update to its Medicare inpatient and outpatient hospital charge databases. Specifically, the updated CMS databases include information on 2012 average hospital charges for the 100 most common Medicare inpatient services and 30 most common Medicare outpatient services. The database now includes two years of data, allowing researchers to begin to look at trends. CMS also has released a variety of information on chronic conditions among Medicare fee-for-service (FFS) beneficiaries, including data on prevalence, utilization, and Medicare spending. In addition, the CMS Geographic Variation Dashboards present Medicare FFS per-capita spending at the state and county levels in interactive formats, and a CMS Research Cohort Estimate Tool is intended to help researchers and other stakeholders estimate the number of Medicare beneficiaries with certain demographic profiles or health conditions.

CMS Releases July 2014 Medicare Part B Drug ASP Update

CMS has released the average sales price (ASP) files that will be used to pay for Medicare Part B drugs for the third quarter of 2014. According to CMS, “average drug prices in the market remain relatively stable,” with prices for the top Part B drugs increasing by 1.8% on average.

Is anybody home? Medicare contractors on the prowl for DMEPOS supplier violations of posted business hours and other physical facility standards.

This post was written by Paul W. Pitts, Carol C. LoepereElizabeth Carder-Thompson, and Nancy Sheliga.

Medicare suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) should be on the alert for enhanced Medicare supplier standard compliance monitoring by CMS, the National Supplier Clearinghouse (NSC), and their agents. Recently, these entities have taken draconian actions to revoke the enrollment of a number of suppliers who failed to be present during indicated hours of operation. Recent Administrative Law Judge (ALJ) decisions have upheld such revocations for technical violation of the Medicare supplier standard, even in the face of extenuating circumstances, reinforcing the need for suppliers to review their practices and policies to ensure full compliance.

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CMS Abandons Plans to Finalize ACA Medicaid Drug Pricing Policy in July 2014

In an email today to stakeholders, CMS announced that it will not be finalizing the ACA Medicaid federal upper payment limits (FUL) for multiple source drugs in July 2014, as previously intended. CMS attributes the change to a delay in providing detailed guidance to the states in preparation for implementation. CMS expects to announce a new finalization date when it releases this subsequent guidance to states.

CMS Announces New Public Comment Process on Requests to Discontinue HCPCS Codes

CMS has announced what it is describing as a “limited demonstration” of an internet-based notice and comment mechanism on requests to discontinue Level II HCPCS codes. The internet-based process would apply to HCPCS discontinuation requests that are generated by CMS based on national program operating needs, and that are not the subject of other notice and comment mechanisms and that are not replaced by other or new codes. CMS contends that this “demonstration” will enhance transparency by providing the public with advance notice and comment opportunity regarding internal decisions to discontinue HCPCS codes. CMS reserves the right to make immediate changes without notice (and take comments afterwards) if it believes there is a national program operating need to do so. The first year of the demonstration will be conducted in the current 2014/2015 HCPCS coding cycle. CMS will publish summaries of internal requests to discontinue permanent level II HCPCS codes by July 1, 2014, and CMS will accept public comments until July 21, 2014.

HHS Launches Second Round of State Innovation Models Initiative

On May 22, 2014, CMS announced the second round of funding under the State Innovation Models Initiative. This initiative was announced in 2013 to support state design and testing of multi-payer payment and delivery models -- such as accountable care organizations, accountable care communities, patient centered medical homes and bundled payments -- intended to generate savings and improve care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. Under round two, CMS will award as much as $30 million for 15 Model Design cooperative agreements (providing funding and technical assistance as states assess system improvement options) and up to $700 million in funding for 12 state-sponsored Model Test cooperative agreements (intended to assist in implementing developed models).

CMS Extends Partial ICD-9-CM and ICD-10 Code Freeze to Reflect Transition Delay

CMS has announced that it is extending its partial ICD-9-CM and ICD-10 code freeze to reflect enactment of legislation (the Protecting Access to Medicare Act of 2014) that prevents the agency from adopting ICD-10 prior to October 1, 2015. Under the new schedule, on October 1, 2014 there will be only limited code updates to both the ICD-9-CM and ICD-10 code sets to capture new technologies and diseases. On October 1, 2015 (the new compliance date for ICD-10 reporting), there will be only limited updates to ICD-10 code sets to capture new technologies and diagnoses; there will be no updates to ICD-9-CM since it will no longer be used for reporting. On October 1, 2016, regular updates to ICD-10 will begin.

CMS to Implement Ordering/Referring Denial Edits for HHA Certifying Physicians, Effective July 1, 2014

CMS plans to apply “Phase 2” ordering and referring denial edits to certifying physicians of Part A home health agency (HHA) services effective July 1, 2014. These edits, which currently apply only to the attending physician of an HHA, will ensure that the physician that certifies the patient’s eligibility to receive services under the Medicare home health benefit has a valid individual National Provider Identifier (NPI) and are of a specialty type eligible to order and refer the HHA items and services on the claim. The edits will deny the claim when this information is missing or invalid.

CMS Announces Reforms to Quality Improvement Organization Program

On May 9, 2014, CMS announced it is implementing the first phase of its reforms to the Quality Improvement Organization (QIO) Program in an effort to “gain efficiencies, to eliminate any perceived conflicts of interest, and to better address the needs of Medicare beneficiaries.” Under this first phase, CMS has named two Beneficiary and Family-Centered Care (BFCC) QIO contractors -- Livanta LLC and KePRO -- to support case review and monitoring activities on behalf of patients, separate from traditional QIO quality improvement activities. Under the second phase, which is expected to be announced in July, CMS will award contracts to organizations that will focus on data-driven quality initiatives intended to improve patient safety, reduce harm, and improve clinical care and transparency.

CMS Extends "Hardship Exemptions" Policy for Health Insurance Purchasers

CMS has provided additional guidance on its evolving hardship exemptions policy for individuals who had difficulty signing up for a qualified health plan (QHP) through an Affordable Insurance Exchange by the March 31, 2014 deadline. As previously reported, in March CMS announced it had established a “special enrollment period” for individuals who were “in line” but could not complete the enrollment process by March 31 deadline; such individuals were permitted to claim a hardship exemption from the shared responsibility payment for the months prior to the effective date of their coverage. According to a subsequent May 2, 2014 guidance document, CMS believes that “some consumers may not have realized that the relief provided by the guidance above was limited solely to those individuals purchasing QHPs through the Marketplace.” CMS therefore is extending a comparable hardship exemption for all months prior to the effective date of coverage for individuals who obtained minimum essential coverage effective on or before May 1, 2014 outside of the Marketplace, whether the individual is in a state with a federally-facilitated Marketplace or a state-based Marketplace. The May 2 guidance also discusses special enrollment periods for individuals eligible for COBRA, individuals whose individual market plans are renewing outside of open enrollment, and AmeriCorps/VISTA/National Civilian Community Corps members.

CMS Announces Changes to Comprehensive End-Stage Renal Disease (ESRD) Care Initiative

CMS has made changes to its Comprehensive ESRD Care (CEC) Initiative to encourage greater participation by both large dialysis organizations (LDOs) and non-LDOs. The goal of the CEC initiative is to improve outcomes for Medicare beneficiaries with ESRD while reducing expenditures by creating financial incentives for dialysis facilities, nephrologists, and other Medicare providers to effectively collaborate on caring for the complex ESRD beneficiary population. In particular, CMS has made changes to the participant owner requirements, the financial risk arrangement, and the financial calculation options. In light of these changes, CMS has reopened the application period; for details on submission dates and additional information, see the CMS web site.

CMS Offers Guidance to Hospitals and States Ahead of DSH Compliance Audits

CMS has released guidance in preparation for State Plan Rate Year 2011 (SPRY) Medicaid disproportionate share hospital (DSH) audits and reports due at the end of 2014. By way of background, on December 19, 2008, CMS published a final rule implementing federal DSH reporting and auditing requirements. CMS provided a transition period to allow adequate time for CMS, states, auditors, and hospitals to work cooperatively in developing and refining DSH reporting and auditing techniques while attempting to mitigate fiscal impact realized by states and hospitals. The SPRY 2011 audits and reports are the first that fall outside of the regulatory transition period.  As discussed in the guidance, CMS will regard audit findings demonstrating DSH payments that exceed the hospital-specific DSH limits as representing discovery of overpayments to providers. The new guidance addresses various operational issues associated with audit protocols and calculation of costs

CMS Posts First Medicare Inpatient Psychiatric Facility Quality Data

On April 17, 2014, CMS announced that it making inpatient psychiatric facility quality data available as part of the Hospital Compare website. Specifically, CMS is now posting data for the period of October 1, 2012 through March 31, 2013 regarding the following measures: Hours of Physical Restraint Use; Hours of Seclusion Use; Post-Discharge Continuing Care Plan Created; and Post-Discharge Continuing Care Plan Transmitted to Next Level of Care Provider Upon Discharge. Next year, CMS also expects to post data regarding the measures “Patients Discharged on Multiple Antipsychotic Medications” and “Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification.”

Older Entries

April 28, 2014 — CMS Issues Call for PQRS Quality Measures

April 16, 2014 — CMS to Implement Fingerprint-Based Background Checks for High-Risk Providers and Suppliers in 2014

April 10, 2014 — Will Physician Payment Sunshine Act Data Usher in a New Era of False Claims Act Litigation?

April 9, 2014 — CMS Releases Physician-Specific Medicare Charge/Payment Data

April 9, 2014 — CMS Announces Final 2015 Medicare Advantage/Part D Drug Plan Rates and Policies

April 8, 2014 — CMS Seeking Comments on Supervision Levels for Select Hospital Outpatient Services

April 8, 2014 — HHS Releases HIPAA Security Risk Assessment Tool

April 8, 2014 — CMS Extends Deadline for Individuals to Enroll in Health Insurance through Exchanges

March 25, 2014 — CMS Finalizes 2014 Policy on Medicare Payment for Hospice Enrollees' Drug Expenses

March 24, 2014 — CMS Releases Subregulatory Guidance on ACA Insurance Coverage, Exchange Issues

March 20, 2014 — CMS Expands Medicare EHR "Meaningful Use" Hardship Exception to Cover Vendor Issues

March 20, 2014 — Medicare Paper Claims Must Be Submitted on Revised 1500 Form By April 1, 2014

March 20, 2014 — Two-Midnight Inpatient Admissions Policy Guidance

March 19, 2014 — CMS Posts April 2014 Medicare Part B Drug ASP Files

March 18, 2014 — "Medicare Care Choices Model" to Allow Certain Hospice Patients to Seek Curative Care

March 4, 2014 — CMS Announces RAC Audit "Pause," Upcoming RAC Program Reforms

March 4, 2014 — CMS Posts Final HIPAA Administrative Simplification Transaction Testing Checklists

March 4, 2014 — CMS Continues to Modify Implementation of 2-Midnight Inpatient Admissions Policy

March 3, 2014 — CMS Proposes 2015 Payment, Policy Updates for Medicare Advantage and Drug Plans

March 3, 2014 — CMS Invites Suggestions for Advanced Diagnostic Imaging Quality/Safety Regulations

March 3, 2014 — CMS to Allow Retroactive ACA Insurance Subsidies for Certain Non-Marketplace Plans

February 18, 2014 — CMS Issues Draft Guidance for Qualified Health Plan Issuers for 2015

February 13, 2014 — CMS Considering Innovative Episode-Based Payment Models for Outpatient Specialty Practitioner Services

February 13, 2014 — CMS Again Extends "Probe & Educate" Phase for 2-Midnight Inpatient Admissions Criteria Implementation; Clarifies Physician Certification Requirements

February 12, 2014 — CMS Outlines 2013 "Sunshine Act" Open Payments Program Registration/Data Submission Process

January 15, 2014 — CMS Loosens Restrictions on Disclosure of Physician-Specific Medicare Payment Data

January 7, 2014 — CMS Steps Up Efforts Aimed at "Recalcitrant" Medicare Providers and Suppliers

January 7, 2014 — CMS Requests Feedback on ACO Initiatives

January 7, 2014 — CMS Revises Hospital Equipment Maintenance Requirements

January 7, 2014 — Hardship Exemption for Individuals with Cancelled Insurance Policies

January 6, 2014 — CMS Invites Comments on Medicare Payment for Hospice Enrollees' Drug Expenses

December 12, 2013 — CMS Releases 2014 Medicare DMEPOS Fee Schedule

December 10, 2013 — CMS Blog Post Announces Delay in Electronic Health Record (EHR) Incentive Program "Stage 3" Meaningful Use Start

December 10, 2013 — Final 2014 Medicare Clinical Lab Rates Set

December 10, 2013 — 2014 HCPCS Update Posted

December 10, 2013 — Updated Medicare Part B Drug Files Released

December 10, 2013 — CMS Proposes Removing 10 Medicare National Coverage Policies

December 9, 2013 — CMS Announces Plans to Finalize ACA Medicaid Drug Pricing Policy in July 2014

November 25, 2013 — CMS Releases Standard Consumer Notices under ACA Grandfathering/Transitional Policy

November 25, 2013 — CMS Letter to States on Quality Considerations for Medicaid and CHIP Integrated Care Models

November 14, 2013 — CMS Announces Medicare DMEPOS Bidding Round 1 Recompete Contract Suppliers

November 14, 2013 — CMS Guidance on Medicare Inpatient Hospital Admissions Two-Midnight Policy

November 14, 2013 — CMS Launches Virtual Research Data Center

November 14, 2013 — Applications for 2015 HCPCS Codes Due Jan. 3, 2014

November 12, 2013 — CMS "Phase 2" Ordering/Referral Denial Edits to Go Live on Jan. 6, 2014

November 11, 2013 — CMS Announces Inflation Update to "Sunshine Act" Reporting Thresholds for 2014

October 31, 2013 — CMS Expects Delay in Release of 2014 HCPCS Update and Final Coding Decisions

October 30, 2013 — Obama Administration Aligns Health Exchange Enrollment Deadline and "Shared Responsibility" Penalty Trigger

October 30, 2013 — IPPS New Technology Add On Applications for FY 2015 Due November 25

October 10, 2013 — CMS Limits Compliance Reviews under New "2 Midnight" Inpatient Admissions Policy

October 10, 2013 — CMS Posts Revised Gapfill Payments for New Molecular Pathology Codes; Reconsideration Requests Due Oct. 30, 2013

October 9, 2013 — CMS Sets 1% Payment Update for Medicare Ambulance Rates in 2014

October 8, 2013 — HHS OCR Releases HIPAA Privacy Rule Guidance Documents

October 7, 2013 — Medicare Rates to Fall by Average of 37% under DMEPOS Competitive Bidding "Round 1 Recompete" Contracts

September 17, 2013 — CMS Issues Guidance on Admission Order and Certification Requirements for Inpatient Admissions

September 16, 2013 — CMS Releases Fourth Quarter 2013 Drug ASP Files

September 10, 2013 — No CMS DME Face-to-Face Rule Enforcement Before 2014

September 5, 2013 — CMS Seeks Input on Advanced Diagnostic Imaging Program

August 27, 2013 — CMS Updates Off-The-Shelf (OTS) Orthotics Listing for 2014

August 27, 2013 — CMS Call on Draft Electronic Clinical Template for Lower Limb Prostheses (Sept. 11)

August 8, 2013 — CMS Invites Comments on Release of Physician-Specific Payment Data

July 29, 2013 — CMS Announces First Temporary Moratoria on HHA, Ambulance Supplier Enrollment in High-Risk Areas under ACA Authority

July 29, 2013 — In Advance of Sunshine Act Reporting, CMS Releases Physician & Industry Resources

June 28, 2013 — CMS Delays DME Face-to-Face Requirement until Oct. 1, 2013

June 27, 2013 — CMS Releases Data on Medicare Outpatient Hospital Payments

June 27, 2013 — CMS Redesigns Medicare Summary Notices

June 27, 2013 — Obama Administration Credits ACA Rules with $3.9 Billion in Insurance Premium Savings, Rebates for 2012

June 27, 2013 — CMS Gears Up for ACA Health Insurance Marketplace/Exchange Launch

June 11, 2013 — July 2013 Update to Medicare ASP Files

June 11, 2013 — CMS Guidance to States on Facilitating 2014 Medicaid, CHIP Enrollment

June 11, 2013 — CMS Invites Comments on Proposed PPS-Exempt Cancer Hospital Quality Measures

June 11, 2013 — Tavenner Confirmed As CMS Administrator

June 6, 2013 — CMS Call on Suggested Electronic Clinical Template for Lower Limb Prostheses (June 13)

May 30, 2013 — CMS to Host July 10, 2013 Meeting on New Clinical Laboratory Test Payment Determinations

May 13, 2013 — CMS Requests Comments on QIO Service Areas

May 13, 2013 — CMS Releases Hospital Charge Data

May 13, 2013 — CMS Sequestration Guidance for State Surveyors, Medicare Part C & D Plans

May 13, 2013 — CMS Announces Preliminary Gapfill Payments for New Molecular Pathology Codes

May 13, 2013 — CMS Accepting Suggestions for Potential PQRS Measures

May 8, 2013 — CMS Actuary Determines No IPAB Cuts Needed in 2015

May 8, 2013 — Updated Draft Medicaid Federal Upper Limit (FUL) Files Posted

May 3, 2013 — CMS Sunshine Act Update: Covered Teaching Hospitals Listing, Industry Efforts, CMS Provider Call

April 30, 2013 — CMS Delays Phase 2 Ordering and Referring Denial Edits

April 16, 2013 — CMS Announces "Winners" of Medicare DMEPOS Competitive Bidding Round 2/National Mail Order Competition

April 16, 2013 — CMS Finalizes Medicare Advantage, Part D Drug Plan Rates for 2014

April 15, 2013 — CMS Resources on Provider EHR Audits

April 15, 2013 — CMS Letter to Issuers on Federally-Facilitated and State Partnership Exchanges

April 15, 2013 — CMS Launches "Medicare Chronic Conditions Dashboard"

March 27, 2013 — CMS Provides More Details on Sequestration Cuts

March 13, 2013 — CMS Issues First Guidance on Sequestration Impact on Medicare

March 13, 2013 — Implementation of Medicare Ordering/Referring Provider Edits (March 20 Call)

March 13, 2013 — CMS Offers Tips and Timelines for ICD-10 Implementation

March 12, 2013 — 2013 Medicare Participation Enrollment Period for DMEPOS Suppliers Extended until April 15, 2013

March 12, 2013 — April 2013 Update to Medicare ASP Files

March 4, 2013 — Medicare and Sequestration - What Happens Now?

February 18, 2013 — CMS Releases FY 2011 RAC Report, RAC "Myths" Document

February 18, 2013 — Tavenner Renominated as CMS Administrator

February 18, 2013 — CMS Invites Applications for New ESRD Care Model

February 18, 2013 — CMS Moves Forward with ACA Bundled Payments for Care Improvement Initiative

January 31, 2013 — CMS Slashes Medicare Reimbursement under Round 2 of the Medicare DMEPOS Competitive Bidding Program/National Mail Order Competition for Diabetic Testing Supplies